Eligibility

• SAG-AFTRA Union members in good standing or on honorable withdrawal
• SAG-AFTRA members that ARE covered under the SAG-AFTRA Health Plan I or Plan II

Eligible Dependents include:

• Your legal spouse
• Your dependent children (dependent children are eligible until age 26)
• Legally adopted children
• Step-children who depend on you for most of their support and maintenance

In order to participate, the individual must be and remain current with any union dues that are required under SAG-AFTRA rules.

Note: Qualified Domestic Partners may enroll in their own individual plan. Click Here to go to the Stand Alone Plan page.

The Dental PPO Benefit

This plan offered by Group Benefit Associates and insured by Cigna gives participants the opportunity to more than double your current coverage and often eliminate any out-of-pocket costs. The Dental PPO Plan is offered in all 50 states.

The Dental PPO plan allows you to visit any dentist or specialist you choose anytime care is needed. If you elect to visit a Cigna network provider, you will receive the highest level of benefits and save on out-of-pocket costs. Best of all, the Cigna Dental PPO Plan features one of the industry’s most extensive nationwide dental networks.

The plan pays a specific amount for each dental service based upon an established fee schedule. If you go to a Cigna Dental PPO provider, the benefits described below apply. If you go to a non-Cigna provider, the amounts charged over the scheduled fees are the patient’s responsibility.

 

	Cigna PPO Advantage	Cigna PPO	Out-Of-Network Providers
Calendar Year Deductible Waived for Preventive services. Cigna deductible is usually satisfied by Delta deductible.	$50 Individual $150 Family	$75 Individual $225 Family	$75 Individual $225 Family
Preventive Services Exams, Cleanings, X-Rays, Fluoride, Sealants, Space Maintainers	25% of fee schedule, no deductible	25% of fee schedule, no deductible	25% of fee schedule, no deductible
Basic Services Fillings, Oral Surgery, Anesthetics, Periodontics, Root Canal / Endodontics Repair Bridge / Crown / Inlays / Dentures	80% of fee schedule, after deductible	50% of fee schedule, no deductible	50% of fee schedule, no deductible
Major Services Crowns / Inlays / Onlays, Dentures, Bridges	50% of fee schedule, after deductible	50% of fee schedule, after deductible	50% of fee schedule, after deductible
Orthodontia	not an insured benefit	not an insured benefit	not an insured benefit
Implants	50% of fee schedule, after deductible, $1000 yearly	50% of fee schedule, after deductible, $1000 yearly	50% of fee schedule, after deductible, $1000 yearly
Plan I Members – Calendar Year Maximum Benefit	$2500, $2700, $2900, $3100 Years 1,2,3,4	$2500, $2700, $2900, $3100 Years 1,2,3,4	$2500, $2700, $2900, $3100 Years 1,2,3,4
Plan II Members – Calendar Year Maximum Benefit	$1000, $1200, $1400, $1600 Years 1,2,3,4	$1000, $1200, $1400, $1600 Years 1,2,3,4	$1000, $1200, $1400, $1600 Years 1,2,3,4
PRE-DETERMINATION: When a course of treatment is expected to cost $200 or more and is of a non-emergency nature, it is recommended to have your dentist submit a treatment plan before he/she begins.

Chart is intended only as a brief summary of benefits. It is not an official statement of those benefits. Please see additional documents under the “Plan Details” tab above.

 

The Vision Benefit

Members currently covered under the SAG-AFTRA Health Plan II DO NOT have a vision benefit. In addition to the Cigna PPO dental benefit, this feature gives Plan II members vision benefits provided through Cigna Vision. Benefits include an annual eye exam for a $10 co-pay along with discounted rates on frames, lenses, and other professional services at network providers. This benefit also includes discounts on all covered services such as LASIK.

Simply visit an in network doctor to receive substantial coverage for annual eye exams and discounts on eyewear and contact lens professional services every 12 months.

You can find a provider near you by:

1. Clicking Find an Eye Doctor to search the online directory.
2. Requesting a provider directory by calling (877) 478-7557.

Covered Services & Value Added Discounts

Eye Exams:

• $10.00 co-pay, covered in full thereafter

Glasses:

• 20% off lenses, frames and the industry’s most extensive list of “cosmetic extras” including tints, special lenses (e.g. progressives) and scratch resistant coatings.
• 20% off the retail price of additional glasses after initial pair is purchased.*

Contact Lenses and Professional Services:

• 15% off of the network doctor’s evaluation and fitting services.
• 20-25% off laser vision correction, or 5% off the laser surgery center’s best promotional price, whichever is a better deal!**

You should call the provider to schedule an appointment. When calling to schedule the appointment, identify yourself as a Cigna participant and provide the insured’s social security number.

*The claimant must go within 12 months to the same doctor who provided the exam.
**Laser surgery is not an insured benefit. The surgery is available at a discounted fee. The covered person must pay the entire discounted fee. In addition, the laser surgery discount may not be available in all states. Participant’s out-of-pocket costs won’t exceed $1,800 per eye for LASIK and $1,500 per eye for PRK.

Dual Coverage – a Great Benefit!

The GBA Supplemental Plan offers a Dual Coverage Feature. This feature allows the Cigna plan to step in to more than double your coverage and will often eliminate your out-of-pocket costs!

With your current insurance, Preventive Services such as cleanings are covered at 100%, but Basic and Major Services are only covered at 75% and 50%. This means you are still responsible for a significant outlay anytime you or a covered family member have any substantial dental work performed.

Preview the few examples below and see how quickly your out-of-pocket costs can add up if you don’t have the GBA Supplemental Coverage.

 

Dental Needs – Each Individual	Dental Charges	Your Cost without GBA Supplemental	Your Cost with GBA Supplemental (Plan I Member)	Your Cost with GBA Supplemental (Plan II Member)
Cleaning (1)	$0.00	$0.00 (1)	$0.00	$0.00
Cleaning (2)	$233.00	$136.00 (2)	$0.00	$0.00
2 surface cavity + composite filling	$236.00	$90.00 (3)	$0.00 (4)	$0.00 (4)
Crown (and all necessary work)	$3,080.00	$1,098.50 (5)	$0.00 (6)	$98.50 (7)

 

Notes:
1	In-network routine cleaning + periodic X-Rays are covered 100% with no deductibles.
2	Out-of-network routine cleaning + periodic X-Rays (Plan II member). Delta allowable charge of $190, less $100 deductible = $90 covered amount at 60%. Your out-of-pocket costs = $136 (40% of $90 + $100 deductible). Cigna reimburses you for 100% of your out-of-pocket costs.
3	Delta allowable charge of $135, less $75 deductible = $60 covered amount from Delta at 75%. Your out-of-pocket costs = $90 (25% of $60 + $75 deductible).
4	Cigna reimburses you for 100% of your out-of-pocket costs.
5	Delta allowable charge of $2,122 less $75 deductible = $2,047 covered amount from Delta. Your out-of-pocket costs = $1,098.50 (50% of $2,047 + $75 deductible).
6	Cigna allowable charge of $2,621 less $1,023.50 paid by Delta = $1,597.50 allowable Cigna claim. Cigna reimburses you 100% of your out-of-pocket costs.
7	Same as (6) above except Cigna benefit is limited to $1,000 for Plan II members.

The Supplemental Dental and Vision Plan is offered as a combined package. All premiums are billed Quarterly.

2021 Quarterly Premium
For Members Covered by SAG-AFTRA Health Plan I
	Participant	Participant + 1	Participant + 2+
Dental PPO	$90.96	$150.06	$228.57
For Members Covered by SAG-AFTRA Health Plan II
	Participant	Participant + 1	Participant + 2+
Dental PPO	$125.19	$205.35	$315.15
VSP Vision	Included	Included	Included

 

Cancellation Requests: Cancellation requests must be received in writing by mail, fax, or e-mail. Cancellations will become effective on the last day of the month in which they are received.

Premium Payments: Your initial premium due will be collected within 5 business days of your enrollment. Subsequent premiums will be collected automatically from a Visa, MasterCard or direct debit from a checking account on March 15th, June 15th, September 15th, and December 15th. If the 15th falls on a weekend or holiday, the charge will occur on the next business day.

Forms & Documents

The following documents below are provided for your reference:

Enrollment Form

Dual Coverage Flyer

Dental Summary – Plan I Members

Dental Summary – Plan II Members

Vision Summary (For Plan II Members)

Dental Claim Form

Vision Claim Form

Parental Consent Form for Children under age 13

 

Frequently asked questions:

Q: How can I cancel my policy?

A: Please send your cancellation request by email, fax or mail.

 

Q: How can I get an ID card?

A: Please call Cigna at 800-244-6224 to request an id card.

DOWNLOAD and print the enrollment form and fax or mail it to us.

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